Description

A 40-year-old previously fit and well man presented with severe dull headache which had begun 26 h prior to presentation, while he was masturbating, and lasted for a  min. It was associated with neck and jaw muscles’ contractions. After 10 min, he then developed a sudden severe thumping headache, at the moment of orgasm, lasting for 20 s suggesting a probable orgasmic headache which left him with a mild headache with reported ‘neck spasm’ for an hour. Thereafter, his symptoms gradually progressed in severity over the next 24 h untill he presented with a severe dull headache. He described these headaches as different from his migraine which is usually associated with a transient blurred vision.

Neurological and systemic examinations were unremarkable. He had normal liver/renal/bone profiles, full blood count and inflammatory markers. His clinical features were suggestive of the first presentation of a benign sexual headache without potentially discriminating factors like lack of convincing objective neck stiffness, focal neurological signs, loss of consciousness or any protracted nature of headache. However, on further direct questioning, his wife reported an ill-sustained witnessed seizure-like activity for few seconds after orgasmic headache.

Making a diagnosis of a primary headache associated with sexual activity on the first presentation requires that structural causes should be excluded1 and due to an unexplained seizure-like activity, a head CT scan was performed which demonstrated acute subarachnoid bleed within the basal cisterns, Sylvian fissures extending over left cerebral convexities and alongside the falx (figures 1 and 2). Subsequently, the patient had CT angiogram which confirmed an anterior-communicating artery aneurysm rupture treated by endovascular occlusion of aneurysm by coil embolisation. He was then discharged 10 days later with no residual focal neurological deficit.

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Figure 1

Axial unenhanced head CT scan view demonstrates high attenuation material within the basal cisterns (arrow 1), Sylvian fissures (arrow 2) and alongside the falx (arrow 3), consistent with subarachnoid haemorrhage.

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Figure 2

Coronal unenhanced head CT scan view showed blood along falx cerebri and slightly more blood on the left side than right around middle cerebral artery (MCA) area (see arrows) raising suspicion of probable left MCA aneurysm as a source of haemorrhage.

An orgasmic headache could be particularly worrisome because 4–12% of patients presenting with subarachnoid haemorrhage due to aneurismal rupture cite sexual activity as the precipitating event.2 ,3 This case reiterates that in patients with a new onset or never-evaluated first presentation of headache with sexual activity; clinicians should remember the vital role of performing neuroimaging (CT/MRI scan of the head) to exclude an underlying potential intracerebral haemorrhage.